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14 Mental Health
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199
stance abuse prior to or during treatment should
be evaluated by a multidisciplinary team, optimally including psychiatrists, therapists, substance abuse counselors, and pain management
specialists. Careful follow-up is required for
patients who express self-harm or suicidal ideation; these patients should be referred expeditiously and may require hospitalization.
In conclusion, the management of mental
health in HNC requires a team approach. HNC
patients require follow-up for the duration of
their treatment and through the survivorship
period for the development of mental health concerns. Oncologists are critical as the “rst line” in
assessing patients, providing appropriate referrals to subspecialists, and implementing medical
therapy where appropriate. A multidisciplinary
therapy team is instrumental in optimizing the
care of these complex patients.
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Physical andOccupational Therapy
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JulianaGomez, DanielleWilson, PatriciaBlack,
LouisFriedman, andAnsleyM.Roche
15
Introduction
Microvascular free tissue reconstruction has
become integral to the surgical care of patients
with locoregionally advanced head and neck cancer. Care and attention dedicated to preserving
the viability of the reconstruction in the postoperative setting remain at the forefront of surgeons’ and patients’ minds. Historically,
mobilization was routinely delayed due to concerns for disrupting the microvascular anastomoses, and patients would often be sedated and
ventilated in the intensive care unit (ICU) for several days after surgery [1, 2]. In the past decade,
J. Gomez
Division of Head and Neck Microvascular and
Reconstructive Surgery, Department of Oral and
Maxillofacial Surgery, Ascension Macomb-Oakland
Hospital, Warren, MI, USA
Wayne State University School of Medicine,
Detroit, MI, USA
e-mail: juliana.gomez@ascension.org
D. Wilson
Touro College of Osteopathic Medicine,
New York, NY, USA
P. Black · L. Friedman
Smilow Cancer Hospital, Yale School of Medicine,
New Haven, CT, USA
A. M. Roche (*)
Division of Otolaryngology—Head and Neck
Surgery, Yale School of Medicine,
New Haven, CT, USA
e-mail: ansley.roche@yale.edu
evidence has emerged that early mobilization
may reduce postoperative complications, ICU
length of stay, and hospital length of stay [3].
While there is no universal protocol for perioperative and postoperative management for
complex head and neck reconstruction, evidencebased recommendations have been described to
minimize postoperative morbidity [4]. These
consensus-based Enhanced Recovery After
Surgery (ERAS) recommendations following
complex head and neck surgery represent an
effort to standardize perioperative and postoperative care; however, only 3 of the 17 recommendations address postoperative mobilization and
physical therapy. Some postoperative complications following head and neck cancer resection
and reconstruction can be avoided with early
mobilization. Additionally, physical and occupational therapy in the immediate postsurgical
period can help to restore function early. These
benets of early mobilization must be weighed
against the importance of preventing injury or
compromise to the reconstructive tissue.
Rehabilitation and physiotherapy after major
head and neck surgery and reconstruction include
not only management of the surgical sites but
also prevention and management of any surgeryrelated loss of function. Postoperative inpatient
physiotherapy addresses the following:
• Respiratory concerns including control of
secretions around surgical sites, decreasing
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Quimby et al. (eds.), Complex Head and Neck Microvascular Surgery,
https://doi.org/10.1007/978-3-031-38898-9_15
201
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J. Gomez et al.
ventilator time, ensuring proper tracheostomy
management or prompt extubation, and managing respiratory distress if present
• Cardiovascular complications, such as dependent edema and prevention of deep vein
thrombosis
• Musculoskeletal complications and functional
limitations, such as muscle stiffness or scarring, joint pain and dysfunction, and weakness
in the head and neck region
Head and neck oncologic surgery can be par-
ticularly challenging due to the vital neurovascular structures present, which are at times intimately
involved with the tumor. Obtaining adequate margins when critical vasculature, sensory and motor
nerves, globes, and theskull base are adjacent to
the tumor results in complex multifaceted defects
that require a challenging reconstruction.
The loss of any vital structure of the head and
neck, whether planned in the resection or unforeseen based on tumor growth, results in complex
and often extended rehabilitation to restore lost
function. Herein, we review different types of
head and neck resections in the context of affected
structures and rehabilitation needs, address
immediate postoperative recovery from major
free tissue reconstructive surgery to the head and
neck, and describe multidisciplinary evidencebased techniques of physical and occupational
therapy in these patients.
Oncologic Defects oftheHead
andNeck
Head and neck resections involving osseous
structures result in defects that without adequate
reconstruction would compromise facial contour
and projection, mastication, sensory and motor
nerve function, and canpotentially result in difculty breathing.
Composite Defects
Composite defects are those consisting of more
than one tissue type including osseous and soft
tissue structures. These defects can be large,
require complex reconstruction, and result in
temporary, and at times permanent, loss of function that requires extensive and prolonged
rehabilitation.
Oral cavity tumors that involve or are located
near osseous structures such as the maxilla or
mandible may result in sensory loss in the distribution of the second and third divisions of the
trigeminal nerve (cranial nerve V), respectively.
Temporomandibular joint (TMJ) dysfunction is
largely dependent on the extent and type of resection, e.g., a segmental resection of the mandible
not involving the joint itself carries concern for
articular head dislocation [5]. For oncologic
resections that involve the temporomandibular
joint (TMJ), consideration must be given to recreating the TMJ with a new articular head, commonly fashioned from the osseous free tissue
being utilized for reconstruction, in order to minimize the severity of TMJ dysfunction postoperatively. While it is critical to evaluate TMJ function
via occlusion and maxillomandibular relationship intraoperatively to ensure the correct position of the native condyle or neo-condyle in the
articular fossa, postoperative manipulation of the
jaw or muscle pull may cause disarticulation and
deviation. There can be postoperative limitations
in jaw range of motion due to inammation, pain,
surgical resection of the condyle and/or coronoid,
and resection of the pterygoid muscles. Trismus,
dened as tonic contraction of the muscles of
mastication resulting in mouth opening of less
than 35mm [6], can affect patients preoperatively
due to tumor involvement of the TMJ or the pterygoid muscles, and patients have reported symptoms of surgery-related trismus as early as the
day of discharge following surgery [7].
Postoperative (chemo)radiation further increases
the risk of trismus as a result of treatment-related
brosis [8]. To prevent trismus, mouth-opening
and jaw range-of-motion exercises are recommended. Optimal timing of initiation of jaw
range-of-motion exercises remains unclear; however, it is recommended to begin as soon as
2 weeks after surgery [9], with some evidence
supporting starting as soon as 1–2days after surgery [10].
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Soft Tissue Defects
mizing speech. Postoperative rehabilitation with
speech and language pathologists is imperative.
Oral Cavity Defects
Defects consisting of soft tissue structures alone
may result in the sacrice of neurovascular structures with resultant loss of function related to the
structures that have been removed. In the case of
oral tongue malignancy necessitating partial,
hemi-, subtotal, or total glossectomy, speech and
swallow function may be impaired, with larger
resections resulting in more signicant impairment of these critical daily functions [11].
Oncologic resection may require removing both
intrinsic and extrinsic tongue musculature. Lip
and buccal cancer necessitating resection of muscles of mastication, muscles of oral competence,
and sensory nerve bers can result in difculty
swallowing some or all consistencies of food and
liquids due to impaired movement of a food bolus
within the oral cavity. Speech and language
pathologists and dietary/nutrition teams should
be involved in the immediate postoperative care
of these patients depending on the type of reconstructive surgery performed.
Laryngeal Defects
In oncologic surgeryof the larynx, the degree of
swallow and speech dysfunction depends on the
extent of the resection. Partial, supraglottic, or
supracricoid laryngectomy results in temporary
dysphagia and voice changes, though as the
remainder of the preserved laryngeal structures
adjust and compensate, swallow and speech
improve with rehabilitation after several weeks
[13]. More extensive laryngeal surgery such as
total laryngectomy or laryngopharyngectomy
renders patients aphonic in the immediate postoperative period. Options for voice rehabilitation
include tracheoesophageal puncture (TEP), electrolarynx, and esophageal speech. Generally,
after 1 week of strict NPO for non-radiated
patients and 2 weeks for previously head and
neck irradiated patients, swallow therapy is initiated under the care of a speech and swallow therapist. Swallow therapy can continue for several
weeks to several months depending on patients’
progress and preexisting swallow function.
Oropharyngeal Defects
Speech and swallow are commonly affected after
oropharyngeal resection and reconstruction [12].
Resection of oropharyngeal structures such as the
superior pharyngeal constrictors, palatopharyngeus, stylopharyngeus muscle, base of tongue
Patients undergoing salvage laryngectomy following (chemo)radiation may have persistent
dysphagia following surgery due to radiationinduced brosis of the pharyngeal musculature
and esophageal stenosis that may require esophageal dilation.
musculature, and motor and sensory nerve bers
of the glossopharyngeal nerve can result in dysmotility and impairment of initiation of deglutition. Resections of the lateral pharyngeal wall
and peritonsillar regions place the carotid artery,
the internal jugular vein, and the vagus nerve at
risk. Reconstruction of this region must provide
adequate coverage to prevent exposure of these
critical structures, especially if patients are to
receive postoperative radiation or have been irradiated prior to surgery. Removing part of the soft
palate may result in velopharyngeal insufciency,
hyper-nasal speech, and dysphagia.
Reconstruction of this area should focus on separating the oropharynx and nasopharynx, restoring
swallow function and nasal breathing, and opti-
Neck Dissection andNeurovascular
Dysfunction
Neck dissection is often performed concurrently
with resection of the primary tumor, either as a
therapeutic or as an elective procedure. The
residual decits following neck dissection depend
on the levels of the neck that are treated and the
vital structures removed at the time. In the past
century, morbidity following neck dissection has
decreased as the number of non-lymphatic structures removed has decreased. Radical neck dissection, rst described by Crile in 1906, involved
removing all lymphatic and non-lymphatic structures of the neck from the mandible to the clavicle with the exception of the carotid artery,
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J. Gomez et al.
lingual nerve, hypoglossal nerve, phrenic nerve,
and brachial plexus. Lymphatic and nonlymphatic structures including the sternocleidomastoid muscle, spinal accessory nerve, internal
jugular vein, omohyoid, and submandibular
gland were removed. Removal of the spinal
accessory nerve and resultant paralysis of the trapezius contributed to painful dysfunction of the
shoulder and upper extremity as described by
Ewing and Hayes in 1952 [14]. Patients reported
cosmetic deformity, difculty abducting the
upper extremity above shoulder level, and discomfort. Over time, surgical technique evolved
as evidence demonstratedsimilar oncologic outcomes and survival when lymphatic only structures were removed and non-lymphatic structures
were spared.
Modied radical neck dissection was
described by Suarez in 1963 [15]. This surgery
spared the sternocleidomastoid muscle, internal
jugular vein, and where possible thespinal accessory nerve, while removing all lymphatic structures of the neck. Surgical technique further
evolved, and now selective neck dissections,
which is the removal of lymph nodes immediately draining the primary tumor site, are commonly performed. Selective neck dissections
have the lowest morbidity of the different types
of neck dissection; however, some patients continue to experience shoulder and upper extremity
disfunction [16]. Spinal accessory nerve dysfunction resulting from neck dissection can be
due to resection of the nerve itself for oncologic
purposes, though it can also occur when the nerve
is preserved, likely due to neuropraxia. Symptoms
of shoulder complaints and dysfunction occur in
18–77% of patients undergoing nerve-sparing
modied radical neck dissections and in 29–39%
of patients undergoing selective neck dissection
[17, 18]. Evaluation of the spinal accessory nerve
pre- and postoperatively includes assessing for
ipsilateral shoulder and neck pain, abduction of
the upper extremity above the horizontal plane,
and head rotation to the contralateral side. These
maneuvers assess the strength of both the trapezius and the sternocleidomastoid muscles. Asking
patients to elevate their shoulder is commonly
done; however, the levator scapulae muscle
assists in this function, so this is not a specic test
for spinal accessory nerve function.
Electromyography testing can be performed to
evaluate the extent of spinal accessory weakness
if there is a decrease in range of motion postoperatively. Further clinical evaluation by physical
exam 2–3weeks after surgery, assessing for bilateral active upper extremity abduction, shoulder
girdle inspection, evaluation for signs of trapezius atrophy, altered position of the scapula, and
“shoulder drop” indicate spinal accessory nerve
dysfunction. The presence of two of three physical signs suggests nerve dysfunction. A single
symptom may be the result of postoperative pain
and immobilization. Some patients experience
symptoms that cannot be attributed solely to trapezius weakness, such as restriction of internal
and external shoulder rotation, forward shoulder
exion, and pain when lying on the involved side,
and it is thought that this may be a result of adhesive capsulitis (AC) of the glenohumeral joint
[19]. Minimizing postoperative immobilization
will reduce the chances of chronic shoulder joint
dysfunction and AC.While the optimum timing
of initiation of physical therapy has not been well
described, it is recommended that patient education and prevention of disuse brosis with the
assistance of a physical therapist be implemented
in the “immediate” postoperative period following neck dissection surgery [16, 20].
Neck dissections that require ligation of the
internal jugular vein place the vagus nerve at risk
for injury. Injury to the vagus nerve will clinically manifest as vocal fold paralysis, dysphonia,
likely dysphagia, and possible aspiration.
Marginal mandibular nerve injury may also occur
during neck dissection, which is clinically evident as weakness in depression of the ipsilateral
lower lip. The hypoglossal nerve is similarly at
risk during a neck dissection at levels 1B and 2A,
as it passes inferior and medial to the digastric
muscle. Injury would result in ipsilateral weakened tongue movement, with tongue deviation
toward the side of injury. If the carotid sheath is
manipulated during the operation, the cervical
sympathetic chain may be injured and manifest
as oculosympathetic palsy, or Bernard-Horner’s
syndrome, a constellation of ipsilateral symp-
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toms that includes ptosis, miosis, and anhidrosis
of portions of the face. The phrenic nerve is occasionally encountered during neck dissections if
there are adherent lymph nodes to the oor of the
neck or at the skull base. Injury to the phrenic
nerve occurs in approximately 8% of radical neck
dissections and results in elevation of the ipsilateral diaphragm. Clinically, this may manifest as
an increased incidence of atelectasis in the postoperative course [21].
After undergoing neck dissections, patients
may experience pain and a decreased range of
motion of the neck. There is often a clinically evident reduction in active cervical extension, exion, and shoulder abduction [22]. To reduce
postoperative neck pain and prevent overstretching the trapezius, it is recommended to use a pillow or arm rest to support the shoulder and upper
arm while seated [23]. A prior history of neck
radiation increases the risk for and severity of
these side effects. Radiation causes muscle brosis, which contributes to decreased range of
motion. Postoperative pain and edema, together
with radiation-induced brosis, can lead to signicant reduction of range of motion, if physiotherapy is not initiated to regain muscle function
[24].
Neck dissections that involve the central compartment place the recurrent laryngeal nerve
(RLN) at risk for injury. The RLN is also at risk
during thyroid surgery, andsacrice of the RLN
results in vocal cord paralysis and decreased sensation within the larynx below the level of the
vocal cords [25].
Lymphedema may also occur following neck
dissections and is typically more pronounced following bilateral neck dissections, compared to
unilateral neck dissection. When this does occur,
manual drainage and compression with multilayered bandages are recommended [23], as will be
discussed in detail below.
Patients who have received prior curativeintent radiation to the neck and who have undergone dissection of the carotid sheath during
surgery are at increased risk of a carotid blowout
approximately 10days to 3months after surgery
[26]. Ideally, range-of-motion exercises after
neck surgery begin around 2 weeks postopera-
tively. This must be weighed against the risk of
carotid artery blowout with patients previously
irradiated to the neck. Fistula formation and
delayed wound healing in the head and neck may
delay initiation of physical therapy since these
factors increase patients’ risk of carotid blowout
[26].
Donor-Site Morbidity
Free ap selection depends on the defect being
reconstructed. In general, resected osseous structures are replaced by osseous free tissue, and soft
tissue structures are replaced with soft tissue free
tissue. There are many factors to consider when
determining which type of free ap is appropriate, such as previous injuries or surgeries that
may have disrupted the blood supply to a potential free ap harvest site, comorbidities such as
peripheral vascular disease and hematologic disorders, and patients’ cardiopulmonary status.
Harvest of different types of free aps carries
risks related to the donor site, and postoperative
physical therapy should be targeted to address
any functional sequelae that may arise after
surgery.
Upper Extremity
Upper extremity free aps are extremely effective in oral cavity reconstruction. Both the radial
forearm free ap and the lateral arm free ap are
slim and pliable, with the RFFF possessing a longer pedicle that can be easily anastomosed to vessels in the neck.
Lateral Arm Free Flap
Song etal. [27] introduced the lateral arm free
ap, which is a soft tissue free ap without an
osseous component. Scar visibility is the most
common morbidity and patient complaint
about the lateral arm donor site. Impaired
elbow mobility is associated with the highest
patient dissatisfaction. It is recommended that
intensive postoperative mobilization is initiated. Paresthesia of the arm has been reported
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J. Gomez et al.
but does not seem to affect patient satisfaction
[28].
Radial Forearm Free Flap
Radial forearm free ap can be either a fasciocutaneous free ap, often used for intraoral reconstruction, or less commonly an osteocutaneous
ap, commonly used for maxillary defects and
short-segment mandibular reconstructions. Prior
to the introduction of prophylactic radial bone
plating, fracture of the forearm was the most
common morbidity associated with this ap [29].
Arganbright’s study [30] of radial forearm
free aps using split-thickness skin graft (STSG)
foundthat tendon exposure is the most common
donor-site morbidity, followed by sensory neuropathy, infection. Radial fracture was the least
common. To improve the success of a STSG,it is
recommended to keep the forearm in a splint for
5–7 days postoperatively [31] protected with
soft dressing and continue full arm mobilization
after the splint is removed, until the wound is
healed [32].
Lower Extremity
Use of the lower extremity in head and neck
microvascular reconstruction has expanded due
to the versatility of the multiple free aps available. Physiotherapeutic considerations are notable due to frequent use of the lower extremity in
daily living and the necessity to return to nearbaseline function. Most commonly used are the
bula free ap (FFF), the anterolateral thigh free
ap (ALT), and the medial sural artery free ap
(MSAP).
Fibula Free Flap
The FFF is a workhorse of head and neck reconstruction. It can be harvested as an osteocutaneous, osteomyocutaneous, or osseous ap and can
be incorporated into a variety of mandibular and
maxillary defects with accompanying soft tissue
defects. However, use of the FFF is not without
donor-site morbidity. Early donor-site morbidity
includes delayed wound healing, wound infec-
tion, partial or total skin graft loss if used, and
wound dehiscence. These sequelae occur in
1–17.4% of patients according to a systematic
review of donor-site morbidity following bula
free ap surgery [33]. Late donor-site morbidity
includes chronic pain typically around the ankle
joint, ankle instability, gait abnormality,
decreased a range of motion, claw toe deformity,
and sensory decits in 3.9–11.5% of patients
[33]. The bula bears between 6.4% and 10% of
body weight with the ankle joint in neutral position and varies with exion, eversion, and loading [34], though it has been theorized “that the
bula is merely a strut that maintains the ankle
conguration and does not actively participate in
weight-bearing” [35].
Lower extremity immobilization follows bula free ap harvest with either a controlled ankle
movement (CAM) boot, posterior plaster splint,
or leg cast. The choice of methodology of immobilization is primarily institution and surgeon
dependent. Regardless of the means of immobilization, it is important to maintain the ankle in
gentle dorsiexion and the toes visible when
placing the dressing to the donor limb. The toes
remain visible to monitor the donor limb for vascular compromise—a rare yet feared complication of FFF harvest.
Generally, the limb remains elevated for 24h
after surgery. Initiation of ambulation varies
across institutions, with some surgeons advocating for early mobilization on postoperative day 1
or 2 [36] according to areview of 157 patients in
which the authors found no association between
incidence of donor-site complications and timing
of ambulation. Other authors have described
waiting until postoperative day 5 if a skin graft is
present [37]. Weight-bearing status is not well
described in the postoperative period. In a review
of 100 patients undergoing FFF, Babovic et al.
described ambulating on postoperative day 2,
without the mention of weight-bearing status
[37]. Others have described non-weight-bearing
walking with crutches and physical therapy on
postoperative day 3. Weight-bearing is increased
gradually at the end of 6weeks; however, crutches
were encouraged for 6months. It is important to
15 Physical andOccupational Therapy
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207
note however that in the patients described, the
bula was used to reconstruct the femoral head;
therefore, the restrictive weight-bearing status
may have had more to do with the recipient site
than the donor site [37]. In head and neck
reconstruction, it is generally accepted that toetouch weight-bearing can be initiated on postoperative day 3, after an initial period of
non-weight- bearing, progressing to full weightbearing around postoperative day 7, under the
direction and care of a physiotherapist [38]. The
leg is to remain elevated when not ambulating,
including when sitting in a chair. Removal of the
splint or cast varies as well by institution—
remaining in place for 3to 7days, depending on
the presence of a split-thickness skin graft. Use
of the CAM boot with ambulation can be offered
to patients for comfort, and duration of use ranges
from 2 to 6 weeks depending on institutional
preference.
Anterolateral Thigh Flap
Since the thigh-based perforator ap was rst
described by Song et al. in 1984 [39], it has
become a reliable and widely used ap in soft tissue reconstruction of the head and neck.
Depending on the defect and reconstruction
goals, the anterolateral thigh ap (ALT) can be
harvested as a fasciocutaneous ap or as a musculocutaneous ap harvested with a portion of
the vastus lateralis. Morbidity following ALT
harvest, while low, can impact hospital length of
stay, postoperative function, and patients’ quality
of life (QOL). A systemic review and pooled
analysis of donor-site morbidity after thigh aps
describe a 0.9% hematoma rate requiring evacuation, 2% seroma rate, and 3.8% rate of wound
dehiscence. Leg contour deformity was described
and was increased when vastus lateralis was also
harvested [40]. Postoperative pain was reported
in 2.6% of pooled cases. Subjective and objective
musculoskeletal dysfunction was reported. While
a reduction of isokinetic contraction force in
20–26% of patients was reported in half of the
studies reporting on musculoskeletal dysfunction, no difference was reported in the other half
of the objective studies, and a pooled analysis
found no signicant decrease in contractile force.
In a mixed-methods study analyzing prospective
and retrospective data on sensory and motor decits following ALT harvest, researchers found
that 82% of patient reported numbness, and the
size of the free ap was associated with 2-point
discrimination scores. At 1 year after surgery,
there was no difference between isometric quadriceps contraction in the ipsilateral (surgical)
thigh compared to the contralateral thigh.
Intramuscular dissection did not appear to have
an impact on motor function nor did the ap size
[41].
Wound dehiscence may prolong hospital stay
for patients whose ALT donor sites are primarily
closed. Harvest of large aps increases the likelihood of dehiscence. A recent study investigating
the impact of incisional negative-pressure therapy (INPT) found that in patients where an incisional negative-pressure system was applied,
there was a lower incidence of dehiscence and
skin necrosis compared to a control group. There
were also fewer overall complications in the
INPT group (7.14%) compared to the control
group (37%), and in a multivariant analysis,
INPT was associated with reduced donor-site
complications, notably in patients with thigh
defects >8cm [42].
Posterior Tibial Flap
The free posterior tibial ap is a soft tissue ap
that has been increasingly used to reconstruct
soft tissue head and neck defects [43]. Overall
morbidity from harvesting the posterior tibial
artery is low, with reports of 87.5% of patients
having no complaints after surgery. In a study of
64 consecutive patients undergoing a posterior
tibial ap for oral cavity defects, no patients
reported difculty walking on ground level; however, weakness and/or fatigue was reported in
10.9% of patients going up and down stairs. No
participants reported cold intolerance. Ankle
movement was not affected postoperatively,
before and after exercise, nor was the anklebrachial index [43].
208
J. Gomez et al.
Torso
There are several frequently used free aps harvested from the torso. The scapula, latissimus
dorsi, rectus abdominis, and deep circumex
iliac artery ap are among the most commonly
used torso ap.
Scapula Free Flap
The scapula ap is a versatile ap that can be harvested as an osseous, osseocutaneous, or megaap if the latissimus dorsi muscle is also
harvested; however, it is typically not the rst
choice for osteocutaneous reconstruction due to
the need to reposition the patient for harvest and
difculty of simultaneous ap harvest and ablation surgery [44]. Postoperatively, it is recommended that the arm of the donor site be placed in
a sling for 3–6 weeks. Some surgeons recommend immobilization period of 2weeks prior to
initiating protected passive range of motion at the
start of the 6th week, begin active range of
motion, and at the 12th week begin strengthening
the shoulder [45]. Others begin physical therapy
on postoperative day 7 with gentle passive movements that continues after discharge for at least
3months [46]. Donor-site morbidity after scapula harvest includes objective (Constant-Murley
score) and subjective (the Disability of the Arm,
Shoulder, and Hand (DASH) test) decreased
range of motion of the upper extremity in many
patients, specically decreased abduction, that
improves with time and does not appear to interfere with the activities of daily living. Seroma
and wound dehiscence tend to occur when larger
skin paddles are harvested [46].
Latissimus Dorsi Free Flap
The latissimus dorsi can be used as a myocutaneous or muscle-only ap. Morbidity following
latissimus dorsi free apharvestincludes numbness and difculties with strenuous activities
such as reaching over the head, vacuuming, and
cleaning windows. Difculty with leisure-time
activities such as tennis and golf has also been
reported [47], andthere is some evidence to support that shoulder joint function may also be
affected [48]. While these impairments may be
acceptable to some patients, they are not negligible and postoperative physical therapy can help
to minimize the level of impairment.
Rectus Abdominus Free Flap
The rectus abdominis ap can also be harvested
as a myocutaneous ap or muscle-only free ap.
Because a portion of muscle is harvested, the
most worrisome complication is and abdominal
hernia [49]. To reduce stress on the abdominal
wall postoperatively, the head of the bed should
be elevated to a 45-degree angle and the patient
may lie in a fetal position on the uninvolved side,
should be advised to avoid Valsalva maneuvers,
and should cough with a pillow up against the
chest. The patient should be taught to use logrolling techniques to avoid disrupting abdominal
sutures while moving around in bed. Abdominal
strengthening exercises usually begin several
weeks postoperatively, with lifting and sit-ups
beginning at 6weeks after surgery [50].
Deep Circumex Iliac Artery Free Flap
The deep circumex iliac artery free apcan be
harvested either as an osteocutaneous or an osteomusculocutaneous free ap. Approximately onequarter of patients report sensory decits, which
is generally the most common sequela reported.
Other donor-site morbidity includes gait abnormalities, chronic pain, and hernia formation.
Aggressive postoperative physical therapy is
thought to reduce potential gait disturbance [51].
Postoperative Physical and Occupation
Physical Therapy
Timing of initiation of physical therapy tends
to be surgeon and institution dependent. Head
and neck surgeons historically have been conservative in postoperative mobilization—citing concern for integrity of the microvascular
anastomoses. Injury to the vascular anastomosis
within the neck after reconstruction is of great
concern to head and neck surgeons in the immediate postoperative period. Historically, patients
were sedated and immobilized for 2–3days postoperatively, although there has been a notable
shift in recent literature advocating for early
mobilization, as soon as within the rst 24hours
following surgery [4]. Early initiation of mobili-
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